CIVEO Early Intervention Form

Patient / Injured Worker Details

Full Legal Name

First NameLast Name

Patient Date Of Birth

DD/MM/YYYY

Patient Email

example@example.com

Patient Phone Number

Please enter a valid phone number.Format: (+61) 0000-000-000.

Injury Details

Injury

Date Of Injury

DD/MM/YYYY

Background Information

Injury Management Advisor/Representative Details

Full Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (+61) 0000-000-000.

Email (a confirmation email will be sent to this address)

example@example.com

Please provide your preferred appointment requirements.

We will endeavour to schedule the closest available day and time to suit your requirements and will email you with the appointment details once confirmed.

Preferred Date

Date

AM or PM? Choose all that apply.

Western Australia or Queensland?

WA Clinics

QLD Clinics

Additional Comments/Notes

Services Requested For CIVEO (Select Multiple If Appropriate)

CIVEO Pre-Approved Early Intervention Package Includes:

Allied Health: 1 x initial session + 3 x subsequent sessions. Further sessions can be provided with IMA approval.
GP appointment at initial and final appointment, for completion of WorkCover medical certificate.
Comprehensive report following first session to be sent to referring IMA
Short email following final approved session or discharge (whichever occurs first) outlining - therapy progression, request for further sessions, discharge for self management or outlining intentions for hand therapy.
Escalation to W/C claim discussion process is via email or phone
Consumables: No limit however must be noted on report/email or GP certificate to identify need.
GP able to order recommended scans if deemed required/essential for management of injury

Relevant Documents/Reports

Please review both links below to our privacy policy prior to completing the form. https://www.redimed.com.au/privacy-policy/

https://www.redimed.com.au/terms-and-conditions/

If multiple discipline services are required, costings will be as per each allied health service separately.
All costings are aligned with the respective state-based Workers Compensation gazetted rates.
Costs are inclusive of all approved consultations, consumables, communication and reports, in line with the state-based Workers Compensation gazetted rates.
Invoicing is completed following each session and will be itemised with consult, report, communication and consumables

I have read the structure of RediMed's Early Intervention Program and understand, agree and consent to the associated early intervention package.

CIVEO Early Intervention Referral